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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004698
Report Date: 09/28/2022
Date Signed: 09/28/2022 12:21:12 PM

Document Has Been Signed on 09/28/2022 12:21 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:KCE CHAMPIONS LLC @ WASHINGTON ELEMENTARY (PS)FACILITY NUMBER:
414004698
ADMINISTRATOR:NGUYEN, KRISTYFACILITY TYPE:
850
ADDRESS:801 HOWARD AVENUETELEPHONE:
(650) 906-2506
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 12TOTAL ENROLLED CHILDREN: 12CENSUS: 6DATE:
09/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Ly ChanhThi and Jacqueline NavarroTIME COMPLETED:
12:30 PM
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On September 28, 2022, Licensing Program Analyst (LPA) Van conducted an unannounced inspection in conjunction with the School-age program's required annual inspection and met with teacher ChanhThi Ly. The purpose of the inspection was explained and granted entry to the facility by the teacher. Present today are 4 children supervised by 2 teachers. The Director, Jacqueline Navarro, arrived a moment later. At 12 pm, two more preschool children arrived. The facility complies with the staff-children ratios today. All staff members have criminal record clearances on file. The Center operates in the portable classroom #16 inside the Washington Elementary School in Burlingame. The days and operations hours are Monday - Friday from 8:30 am to 5:00 pm.

LPA toured and inspected the physical plant for any health and safety hazards. The facility has a record of sign-in/out of children. All parents' signatures matched and accounted for the number of children present. The facility is in good repair and has proper temperature and ventilation. Furniture appears steady and in good repair. The facility has a carbon monoxide detector, a centralized smoke alarm, fully charged fire extinguishers, and a working telephone. LPA observed that each child has their cubbies available with their name labeled. The Director stated the facility does not have any children with medications but has a medication storage box. Director was aware all medications required proper labeling, unaltered, that and parental consent. First aid supplies are fully stocked and available for children's use. All cleaning solutions, poisons, and other dangerous chemicals are stored inside the high cabinet in the classroom Sleeping cots are appropriately stored.
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SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: KCE CHAMPIONS LLC @ WASHINGTON ELEMENTARY (PS)
FACILITY NUMBER: 414004698
VISIT DATE: 09/28/2022
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The facility had posted the required forms. (i.e., License, Notification of Parent's Rights, Notification of Personal Rights, Car Seat Law, Emergency Disaster Plan, and Daily activities). Per the Director, the Center does not provide food for the children. The daily schedule is observed posted. The facility has water fountains readily available for children indoors and outdoors. All storage containers for solid waste within the Center have a proper tight-fitting cover. The classroom has two toilets and two sinks for children, and the staff has a separate bathroom. All toilets and handwashing sinks are in good working condition with proper sanitation. LPA observed no bodies of water on the premises. The Outdoor play area is required to have sectioned off with cones. The Outdoor play area will be shared with School age children. LPA reminded the Director that staff must ensure there is no co-mingling of Preschool children with School Age children

All children's records and personnel records were reviewed during the inspection. Records review showed the facility has records of each child's authorized representative's names, addresses, and telephone numbers. In addition, each child's immunization record, medical assessment, and admission agreement can be located in each child's file. Staff records indicate that all staff or individuals requiring caregiver background checks have received criminal records and child abuse index clearances or exemptions. Multiple staff members have a record of valid CPR and maintain proper immunization records. LPA reviewed the educational qualification of the Director and staff, and all staff had the required ECE units. The Director stated that the Center conducts fire and earthquakes at least once every six months, and the last drill was conducted on 9/15/2022.

The Director was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption or transfer their existing clearance or exemption prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated. Continued on page 3...
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: KCE CHAMPIONS LLC @ WASHINGTON ELEMENTARY (PS)
FACILITY NUMBER: 414004698
VISIT DATE: 09/28/2022
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The incidental Medical Services (IMS) policy was discussed. For IMS information, see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to the publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

The Director was informed about Mandated Reporter training. In addition to AB1207 training required to complete every two years by the Licensee and all staff hired, a one-time General Training is also required. Training can be taken online at www.mandaterreporterca.com. Also, the Director was reminded of Pesticide training. Information on the DPR website at: www.cdpr.ca.gov/shoolipm/childcare

LPA encouraged the Director to visit the Licensing website at www.ccld.ca.gov for licensing regulations and new updates. Director can also email at childcareadvocatesprogram@dss.ca.gov and ask for the updates to be added to the email list.

During the inspection, LPA requested the following documents to be sent to Licensing office by October 5; Designation of Administrative Responsibility (LIC 308) and updated Basic Pest Management Training for staff.





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SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: KCE CHAMPIONS LLC @ WASHINGTON ELEMENTARY (PS)
FACILITY NUMBER: 414004698
VISIT DATE: 09/28/2022
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**** This is an amended report****
To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

No deficiencies are cited today. An exit interview was conducted, and the report was reviewed with the Director, Jacqueline Navarro. Today's report, September 28, 2022, and notice of site visit were provided to the Director. LPA informed the Director that the site visit notice must be posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022
LIC809 (FAS) - (06/04)
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